Uncategorized – Page 15 – The FOAMed Quiz

November 21, 2019November 20, 2020

Quiz 51, November 21th, 2019

Welcome to the 51th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Your patient presents to the Emergency Care because of worsening binocular diplopia since yesterday. She does not complain of a headache and no fever is present. On physical examination you find bilateral ataxia and areflexia without hemiparesis. No additional abnormal findings are found. Which of the following diagnosis is the likely ?

A: Myasthenia Gravis

B: Claude Syndrome

C: Botulism

D: Miller Fisher variant of Guillain Barré Syndrome

Reveal answer

The correct answer is D

NUEM covered diplopia this week.

Myasthenia Gravis can present with isolated diplopia, but one would not expect areflexia and ataxia. Often ptosis is present as well.
Claude syndrome is caused by a midbrain infarct and typically includes unilateral oculomotor or trochlear palsy with contralateral ataxia. One would not expect worsening of symptoms over time and bilateral ataxia.
Botulism should be considered, but does not cause areflexia until a muscle group is paralyzed.
This set of symptoms (diplopia, areflexia and ataxia) is typical for Miller Fisher variant of Guillain Barré syndrome.

Question 2

You see a 27 year old G4P2 female at 25 weeks of gestation at the emergency department (ED) with right upper quadrant abdominal pain and vomiting. While abdominal pain during pregnancy is an extremely common complaint, medical emergencies should be considered.

Which of the following statements is true about medical emergencies in pregnant women:

A: Risk factors for uterine rupture include blunt abdominal trauma, grand multiparity and prior cesarean sections or myomectomies

B: Diagnostic criteria of HELLP syndrome include: proteinuria, leukocytes >12, AST and ALT ≥ 2x the upper limit of normal and platelet counts <100,000 x 10⁹/L

C: The ‘’discriminatory zone’’ describes that there is a certain ß -hCG level above which the gestational sac associated with a normal intrauterine pregnancy should reliably be visible on ultrasound. In case of transvaginal ultrasound (TVUS) this has been set at >500 mlU/ml

D: Physical examination in women with Pelvic Inflammatory Disease (PID) typically reveals lower abdominal pain and cervical motion tenderness. Treatment of PID in pregnant and non-pregnant woman is the same

Reveal answer

The correct answer is A.

EMdocs covered pathologic obstetric abdominal pain this week and provided some useful summaries of notable signs in these conditions.

Uterine rupture most commonly occurs at the site of prior uterine surgical manipulation such as scar sites of prior cesarean sections or myomectomies. It most commonly occurs during labour but it should also be considered in blunt abdominal trauma in pregnant woman.

HELLP syndrome is a severe form of preeclampsia and is associated with hemolysis, transaminitis and thrombocytopenia. It is often associated with hypertension and proteinuria but these elements are not necessary for the diagnosis.

The ß -hCG level in the ‘’discriminatory zone’’ has traditionally been set at >1500 mlU/ml for TVUS but recently the American College of Obstetrics and Gynecology set this value conservatively high at >3500 mlU/ml. If no intrauterine gestational sac is visible on TVUS, an ectopic pregnancy should be considered.

PID is an infection of the upper genital tract (uterus, endometrium, fallopian tubes and ovaries) in women and is mostly caused by sexually-transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis. Pregnant women are treated with a second generation, cephalosporin and azithromycin, since regimens using doxycycline should be avoided during pregnancy due to adverse fetal effects.

Question 3

You treat a patient with septic shock. After fluid resuscitation, antibiotics and the start of norepinephrine at 5 microgram per minute your patient is not improving. According to this recently published study about the non-catecholaminergic vasopressor Selepressin you should:

A: Start selepressin at 3.5 ng/kg/min in addition to norepinephrine

B: Stop norepinephrine and start selepressin at 3.5 ng/kg/min

C: Start selepressin at 1.7 ng/kg/min in addition to norepinephrine

D: Not start selepressin

Reveal answer

The correct answer is D

RebelEM covered this recently published paper last week.

This study addresses an important question about whether adding a second vasopressor with a different action mechanism has an effect on the outcome in refractory septic shock. The authors did not find any significant difference in primary outcomes as vasopressor and ventilator free days. However, the study did show some differences in secondary outcomes (norepinephrine requirement and urine output).

SEPSIS-ACT: Selepressin in Septic Shock

Question 4

Source image: https://emergencymedicinecases.com/

Your patient presents with suspected hook of Hamate fracture. Which of the following statements is true about this condition?

A: Patients may have decreased grip strength and can endorse numbness in the 2th and 3th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate

B: Hook of hamate fractures almost always require open reduction internal fixation (ORIF)

C: Hook of hamate fractures can be managed conservatively with a short arm cast

D: Excision of the fractured portion of the hamate is never indicated

Reveal answer

The correct answer is C

AliEM covered Hook of Hamate fractures this week.

Patients may have decreased grip strength and can endorse numbness in the 4th and 5th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate. ORIF is possible but has little benefit. Excision of the fractured portion of the hamate is sometimes indicated. And yes, hook of Hamate fractures can be managed conservatively with a short arm cast.

SplintER Series: Pain in the Palm

Question 5

A number of methods are used to estimate the weight of pediatric patients. Which of the following methods was most accurate according to this recently published paper?

A: Parent estimation

B: Broselow tape

C: The Mercy Method

D: The APLS formula

Reveal answer

The correct answer is A

JournalFeed covered this paper last week.

Parent estimation was within 10% of actual weight 89% of the time and within 20% of actual weight 97% of the time. The Broselow tape came second and the APLS formula and the Mercy Method were less accurate. Bear in mind this study was conducted in Thailand.

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

November 14, 2019November 20, 2020

Quiz 50, November 14th, 2019

Welcome to the th FOAMed Quiz.

This weeks Quiz is about Cardiogenic Shock, PSA and Testicles.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Which of the following statements is correct regarding diagnosis and management of cardiogenic shock?

A: Dobutamine should almost always be first line treatment in cardiogenic shock

B: Patients in cardiogenic shock are not always hypotensive

C: Milrinone is easy titratable in the Emergency Department

D: Intra Aortic Balloon Pumps (IABPs) increase cardiac contractility

Reveal answer

The correct answer is B

In the latest very interesting EMcrit podcast, Scott Weingard discusses cardiogenic shock with Jenelle Badulak.

Starting dobutamine without a vasopressor can cause vasodilatation and hypotension. Patients in cardiogenic shock are quite often normotensive. Milrinone is not easy to titrate, especially in patients with suspected kidney failure. And finally, AIBPs do not increase cardiac contractility directly.

EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak

Question 2

NUEM covered the basics of Procedural Sedation and Analgesia (PSA) this week. Which of the following statements is true?

A: Third trimester pregnant patients do not have an increased chance of vomiting

B: Midazolam can safely be used in pregnant patients

C: End tidal (Et) CO2 provides earlier detection of hypoventilation

D: Ketofol is clearly superior to Ketamine and Propofol alone

Reveal answer

The correct answer is C

Yes, pregnant patients do have an increased risk of vomiting. This is one of the reasons PSA is rarely performed in the Emergency Department in pregnant patients (at least in our shop). Some benzodiazepines have been shown to be teratogenic, so midazolam should not be used. EtCO2 does provide earlier recognition of hypoventilation, although false positives occur (apnea on etCO2, but still breathing). Evidence is mixed on Ketofol. Although in theory lower doses of ketamine and propofol are necessary and chance of side effects smaller, you will have to deal with the side effects of 2 drugs instead of 1.

Question 3

Which of the following statements is true about patellar sleeve fractures?

A: Injury to the proximal pole typically leads to avascular necrosis of the proximal portions

B: Patellar Sleeve Fractures are the most common type of patellar fractures in pediatric patients

C: Patellar sleeve fractures occur most often due to powerful contraction of the hamstrings while knee is extended

D: Patellar sleeve fractures are easily seen on conventional X-ray

Reveal answer

The correct answer is B

Pediatric EM Morsels covered patellar sleeve fractures this week.

Blood supply to the immature patella comes from the distal pole and the anterior surface. Therefore, injury to the anterior or distal pole can lead to avascular necrosis of the proximal portions. Patellar sleeve fractures are quite often due to powerful contraction of the quadriceps while the knee is flexed. Patellar sleeve fractures are easily missed on conventional X-ray. MRI might be necessary for diagnosis. And indeed, a Patellar Sleeve Fracture is the most common type of patellar fracture in pediatric patients. Most fractures require open reduction and internal fixation.

Patellar Sleeve Fracture

Question 4

An 18-year old male is seen in the emergency department with sudden onset severe pain in his right testicle. His pain increased over time and is now 9/10.

Which of the following is true about testicular torsion?

A: Testicular torsion is equally common in all age groups

B: At 4 hours after onset of symptoms, damage to the testicle is irreversible.

C: Absence of cremasteric reflex is the most sensitive and specific clinical finding in diagnosing testicular torsion

D: Isolated tenderness at the superior pole of the affected testicle is not a very specific sign for torsion

Reveal answer

The correct answer is C

Testicular torsion was covered by CanadiEM this week.

Testicular torsion should be considered in every patient presenting with testicular pain although it is most prevalent in the pediatric population. Irreversible damage is more likely to be present if torsion consists for 8 hours or more. An absent cremasteric reflex is very sensitive and specific and can help to distinguish between testicular torsion and other conditions like epididymitis. Isolated tenderness at the superior pole of the affected testical is very specific for testicular torsion.

Testicular Torsion

Question 5

In critically ill patients admitted to the hospital and receiving at least 48 hours of oxygen therapy, what would be the range of oxygen saturation associated with the lowest adjusted mortality according to this recently published paper?

A: 90-94%

B: 92-96%

C: 94-98%

D: 96-100%

Reveal answer

The correct answer is C

JournalFeed discussed this Singaporean paper last week.

No big surprise in this recently published paper. Retrospective analyses were conducted of two electronic medical record databases: the eICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care III database (MIMIC). Nonlinear regression was used to analyze the association between median pulse oximetry-derived oxygen saturation (Spo2) and hospital mortality. The optimal range of Spo2 was 94% to 98% in both databases (total of > 35.000 patients).

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

November 8, 2019November 20, 2020

Quiz 49, November 8th, 2019

Welcome to the 49th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Winter is coming! This means people start warming their houses. Unfortunately this is not always been done in a safe way.

Which of the following statements is true about carbon monoxide (CO) poisoning?

A: Carbon monoxide poisoning is always caused by inhaling gas

B: There is a validated relationship between carboxyhemoglobin levels and specific symptoms

C: Half-life of carbon monoxide at 100% FiO2 is ~1 hour

D: Arterial Blood Gas (ABG) is preferred to Venous Blood Gas (VBG) for diagnosis of CO poisoning

Reveal answer

The correct answer is C

The internet book of critical care covered carbon monoxide poisoning this week.

Exposure to methylene chloride (paint remover) can cause CO poisoning (after being metabolized). This can occur several hours after exposure. There is no validated relationship between carboxyhemoglobin levels and specific symptoms. VBG is accurate for diagnosing CO poisoning. And the half-life of carbon monoxide at 100% FiO2 is ~1 hour (at 21% FiO2 ~5 hours, at 250% (hyperbaric oxygen)~20 minutes)

IBCC chapter & cast – Carbon monoxide poisoning

Question 2

Justin Morgenstern covered the coronary CT angiography (CCTA) on First10EM this week. Which of the following is true about the use of CCTA in patients with suspected Acute Coronary Syndrome (ACS) seen in the Emergency Department?

A: CCTA improves 30-day mortality

B: CCTA leads to a decrease in length of stay, but only if you have incredibly long lengths of stay to begin with

C: CCTA causes a huge increase in radiation

Reveal answer

The correct answer is B

All relevant papers about this topic were briefly reviewed. It seems CCTA does not provide any clinical benefits over standard care. However, ‘’the patients enrolled in these studies were so low risk that they could not have possibly benefited from further testing.’’ So a role for CCTA is not fully excluded.

Question 3

You intubate a critically ill patient and you struggle with correct placement confirmation since capnography malfunctions. You decide to use ultrasound. Which of the following statements is true?

A: A bullet sign suggests oesophageal intubation

Bullet Sign. Source: https://www.nuemblog.com/

B: A double tract sign suggests endotracheal intubation

Double tract sign. Source: http://www.emdocs.net/

C: Ultrasound assessment has about 98% sensitivity for tracheal intubation

D: In ultrasound assessment of tracheal intubation the probe should be placed superior to the suprasternal notch in a longitudinal orientation

Reveal answer

The correct answer is C

NUEM covered Ultrasound Confirmation of Endotracheal Tube Placement this week.

A bullet sign suggests endotracheal intubation. A double tract sign suggests oesophageal intubation. In ultrasound assessment of tracheal intubation the probe should be placed superior to the suprasternal notch in a transverse orientation. Ultrasound assessment has about 98% sensitivity for tracheal intubation.

Question 4

Which statement is true about dizziness and vertigo?

A: Associated neurological complaints, such as imbalance, dysarthria, or numbness raise the likelihood of TIA or stroke

B: When performing the Hallpike test, the head should be turned to the side 90 degrees prior to laying the patient back into the head-hanging position

C: The presence of auditory symptoms suggest a central cause of the vertigo

D: Vertigo after neck injury and is usually benign

Reveal answer

The correct answer is A

CanadiEM covered dizzyness and vertigo in Crackcast episode 207

When performing the Hallpike test, the head should be turned to the side 45 degrees prior to laying the patient back into the head-hanging position. The presence of auditory symptoms suggest a peripheral cause of the vertigo. Neck injury can cause vertigo from vertebral artery dissection, resulting in posterior circulation ischemia.

CRACKCast E207 – Dizziness and Vertigo

Question 5

Which statement about urolithiasis is true?

A: Prevalence of kidney stones is higher in a cold and wet climate

B: A restrictive calcium diet decreases the risk of stone formation

C: Microscopic hematuria is present in only 50% of the patients

D: Intravenous (IV) hydration has no impact on stone passage

Reveal answer

The correct answer is D

Daniel Tauber covered urolithiasis last week on emDOCs.

He clarifies why a calcium restrictive diet will not help to prevent urolithiasis, but paradoxically increases the risk of stone formation. He also emphasizes that the lack of microscopic hematuria can not be used to rule out kidney stones, since the sensitivity is only 85%. Prevalence is higher in hot, dry, arid climates such as mountain, desert, or tropical regions. IV hydration has no impact on stone passage.

EM@3AM: Urolithiasis

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

November 1, 2019November 20, 2020

Quiz 48, November 1th, 2019

Welcome to the th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Due to some changes in our e-mail notification system it is possible our e-mail ended up in your Spam inbox. If you didn’t receive a notification e-mail at all or if you did not yet subscribe to receive an e-mail every time a Quiz is posted, please contact us at rick@thefoamedquiz.org.

Thanks!

Question 1

As emergency physicians we see a lot of septic patients coming into our emergency departments (ED’s). As early as possible administration of antibiotics sometimes conflicts with obtaining blood cultures before administration of these antibiotics. A recently published study, discussed in JournalFeed this week, compared positive blood cultures taken before and after administration of antibiotics.

What did this study find?

A: Administration of antibiotics before drawing blood cultures makes it harder to culture causative bacteria

B: The rate of positive blood cultures is the same as long as blood cultures are taken within 2 hours after administration of antibiotics in the ‘after’ group

C: It is reasonable to delay admission of antibiotics so blood cultures can be taken before the antibiotics will be administered, even if the patient is very ill

D: Timing does not matter at all, just make sure blood cultures are taken before the patient leaves the ED

Reveal answer

The correct answer is A

This recently published paper in Annals of Internal Medicine by Cheng et al. (september 2019) was discussed on JournalFeed this week and also reviewed by Rory Spiegel.

Cheng et al. included a total of 325 patients (aged 18 years and older) with severe sepsis (defined as having two SIRS criteria with a suspected or confirmed infectious source and either hypotension or a serum lactate > 4 mmol?L) from seven emergency departments. The data add proof to the long held belief that blood cultures should be taken before antibiotics are administered. However, sometimes antibiotics just need to be administered as soon as possible without any delay caused by taken blood cultures first.

EM Nerd-The Case of the Microscopic Imperative

Question 2

Last year 1182 people were diagnosed with measles in the United States. This was the highest number since 27 years. Emergency Physicians should be aware of this disease, especially in children with fever seen at the Emergency Department. Which of the following is true about Measles?

A: The ‘’classic’’ prodromes consist of: fever, conjunctivitis, and upper respiratory tract infection symptoms

B: Patients are only infectious in the first 48 hours after the onset of the maculopapular rash

C: The most common complication of measles is encephalomyelitis

D: If vaccinated, a child is 100% protected against the virus.

Reveal answer

The correct answer is A

Last week ALiEM discussed measles.

The classic prodrome of symptoms consist of fever, conjunctivitis and upper respiratory tract symptoms. Children are infectious for 4 days before and 4 days after the onset of the rash. Measles are mostly if not always seen in children who are not vaccinated. Only 3% of vaccinated children get measles if regularly exposed. Only 1 in 1000 patients get encephalomyelitis. The complication of the measles leading to most deaths is pneumonia which occurs in 30% of hospitalized patients and is responsible for 60% of the deaths.

Measles 2019 Updates: The Comeback Kid

Question 3

Source: https://dontforgetthebubbles.com/

Last weeks post on Don’t Forget the Bubbles is about two kinds of palsy that can occur in the pediatric population; phrenic nerve palsy and Erb’s palsy. Which of the following statements is true ?

A: Phrenic nerve palsy’s most common cause is birth trauma

B: Erb’s palsy’s most common cause is birth trauma

C: Half of the patients with Erb’s palsy have associated phrenic nerve palsy

Reveal answer

The correct answer is B

Phrenic nerve palsy causes hemidiaphragmatic paralysis, which compromises respiratory function. The most common cause is thoracic surgery, but can also occur with birth trauma. Mortality is reported up to 19 percent, and is even higher with delayed treatment. Treatment includes supportive respiratory care and most of the time surgical intervention. Erb’s palsy is a complex brachial plexus injury that causes paralysis of the arm. Most common cause is birth trauma, and most babies recover fully. There are similar risk factors for both palsies and in 2.4 percent of the patients with Erb’s palsy there is associated phrenic nerve palsy.

Question 4

Splenic abscesses are a rare condition, with an annual incidence rate of 0.05 – 0.7%. Despite this low incidence rate, it is important to have a high clinical suspicion of the condition in a subset of patients.

What is an important risk factor for the development of splenic abscesses, and which clinical findings can be expected?

A: Risk factor: endocarditis. Symptoms: generalized abdominal pain, diarrhea, leukopenia

B: Risk factor: deep skin infections. Symptoms: generalized abdominal pain, diarrhea, leukopenia

C: Risk factor: endocarditis. Symptoms: left upper quadrant pain, hiccups, leukocytosis

D: Risk factor: deep skin infections. Symptoms: left upper quadrant pain, hiccups, leukocytosis

Reveal answer

The correct answer is C

EMdocs covered splenic abscesses last week. Early recognition of the condition is important for mortality rates are significant in missed or delayed diagnosis.

Splenic abscesses are quite frequently secondary to endocarditis. Risk factors include immunosuppression, prior splenic infarction, splenic trauma or hemoglobinopathies. Patients commonly present with fever, left upper quadrant pain and vomiting. In case of diaphragmatic irritation, patients usually have left shoulder pain and hiccups as well.

Splenic Abscess: ED Presentation, Evaluation, and Management

Question 5

Your 55 year old patient presents with diaphoresis, confusion and hypotension. During primary survey you notice a battery pack on his side and you realize he has a Left Ventricular Assist Device (LVAD). As the first sweat drops start to appear on your forehead, you try to remember everything you know about LVAD’s. Which of the following statements is true?

A: The LVAD patient will have a palpable pulse

B: The mean arterial pressure (MAP) should be measured with a doppler and a sphygmomanometer

C: On auscultation you shouldn’t be able to hear the device

D: The MAP goal for the majority of LVAD patients is between 40-60 mmHg

Reveal answer

The correct answer is B

BrownEM covered LVAD issues this week.

The LVAD patient will most likely not have a palpable pulse, nor a measurable blood pressure. The mean arterial pressure (MAP) should be measured with a doppler and a sphygmomanometer. On auscultation, the physician should be able to hear the hum of the device. The MAP goal for the majority of LVAD patients is between 70-90mmHg.

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

October 25, 2019November 20, 2020

Quiz 47, October 25th 2019

Welcome to the 47h FOAMed Quiz.

Please feel free to comment and (if you like it) share.

Enjoy!

Kirsten, Eefje, Hüsna, Nathalie and Rick

Question 1

Last week the CRASH-3 trial was published in the Lancet. It is about the effect of tranexamic acid (TXA) in patients with acute traumatic brain injury with a Glasgow Coma Scale of ≤ 12 or intracranial hemorrhage without significant extracranial bleeding.

What did the authors find?

A: Treatment with tranexamic acid is safe and reduces head injury related death in patients with an initial GCS of 9 and higher

B: Treatment with tranexamic acid reduces head injury related death in patients with an initial GCS of 3 to 8

C: Treatment with tranexamic acid does not reduce head injury related death

Reveal answer

The correct answer is A

The CRASH-3 trial is a massive double-blind RCT involving 175 hospitals in 29 countries.

About every Emergency Medicine blog and podcast covered this paper last week and rightfully so.

The Resus Room, St Emlyn’s, EMlitofnote, JournalFeed, RebelEM and EMCrit are among those.

In short:
It is a massive and well conducted trial.
Only secondary analysis of an underpowered subgroup was found to be statistically significant (head injury related death in patients presenting with a GCS of 9 and above).
TXA seems to be safe, but Pulmonary Embolism and Deep Venous Thrombosis were only diagnosed when found positive by accident on imaging or post-mortem examination.

Question 2

Do we need to give a fluid bolus before intubation? The PrePARE Trial investigated the effect of a fluid bolus (500 cc) versus no bolus in critically ill adults undergoing tracheal intubation. The primary endpoint was a composite of post-intubation complications including new-onset hypotension (systolic Bp <65 mm), new or increased vasopressor administration, or cardiac arrest.

What is true according to the PrePARE trial?

A: A fluid bolus prevents hypotension caused by intubation

B: A fluid bolus increases the risk of a cardiac arrest

C: A fluid bolus leads to increased administration of vasopressors

D: There was no difference in primary outcome between giving a fluid bolus or not

Reveal answer

The correct answer is D

The PrePARE trial is a multicenter RCT that investigated patients undergoing endotracheal intubation. Prior to intubation patients were randomized to receive 500 cc fluid bolus versus no bolus. The study was stopped early for futility after including 337 patients. The outcome in both groups were exactly the same.

PulmCrit Wee: Do fluid boluses before intubation help? (PREPARE trial)

Question 3

Which of the following statements is true about hydrocarbon poisoning?

A: Cardiovascular complications are the most commonly reported adverse effect

B: Hydrocarbons are believed to produce a decrease in myocardial sensitization to endogenous and exogenous catecholamines

C: Beta-blockers like esmolol may provide benefit in the treatment of hydrocarbon poisoning

D: Topical exposure to hydrocarbons does not cause harm

Reveal answer

The correct answer is C

emDocs covered hydrocarbon poisoning this week.

Pulmonary complications are the most commonly reported adverse effect. Hydrocarbons are believed to produce an increase in myocardial sensitization to endogenous and exogenous catecholamines. Topical exposure to certain hydrocarbons can cause cell membrane injury leading to burns and skin necrosis from prolonged contact. And indeed, esmolol may provide benefit in the treatment of hydrocarbon poisoning by decreasing the myocardial sensitization to catecholamines.

TOXCard: Hydrocarbon Toxicity

Question 4

The management of uncomplicated atrial fibrillation in the emergency department (ED) is an ongoing topic of discussion. Recent literature suggests we shouldn’t try to achieve sinus rhythm in stable atrial fibrillation. But if you still wanted to cardiovert a patient with stable atrial fibrillation, what would be the best method?

This study compared initial electrical (and secondary chemical cardioversion in not successful) versus initial chemical cardioversion (and secondary electrical cardioversion in not successful).

What difference did the authors find?

A: The length of stay (LoS) in the emergency department was longer in the chemical cardioversion first group

B: Patients undergoing chemical cardioversion first were more likely to be discharged home

C: ED revisits were fewer in the electrical cardioversion group

Reveal answer

The correct answer is A

This RCT compares procainamide-first versus electrical cardioversion-first approach for patients presenting in the emergency department with uncomplicated atrial fibrillation. 84 patients were included. The authors conclude that both strategies are successful and well tolerated. The length of stay in the ED was shorter in the cardioversion-first group (no surprise there). They found no difference in QOL, ED revisits and all patients were discharged home after the initial visit (no surprise there either).

Comparison of Chemical vs Electrical Cardioversion of Acute Uncomplicated Atrial Fibrillation

Question 5

Your 24 year old female patient presents with right lower quadrant abdominal pain for 3 days, you consider appendicitis. There is no fever, but blood works show mild leukocytosis. The abdominal ultrasound is inconclusive (appendix is not seen) and by hospital policy you order an MRI. Given the pretest probability of your patient having appendicitis is 20% and MRI has a 80% specificity (and close to 100% sensitivity) in diagnosis of appendicitis, what is the chance this MRI will turn out to be false positive?

A: 24,5%

B: 34,5%

C: 44,5%

D: 54,5%

Okay, your next patient is also 24 years old and presents with right lower quadrant abdominal pain since 5 days. Blood works do not show abnormalities but you still order an ultrasound, which turns out to be inconclusive. Again, by hospital policy you proceed to MRI (specificity 80%). In this case the pretest probability has fallen to 5%. What is the chance this MRI will turn out to be false positive?

A: 40%

B: 60%

C: 80%

D: 90%

Reveal answer

The correct answer to the first part is C, 44,5%

The correct answer to the second part is C, 80%

Justin Morgenstern points out once more You can’t interpret the results of a test without knowing the pretest probability.

The first part: In every 1000 patients, 200 will have appendicitis. Given the sensitivity is 100% these 200 patients will have a positive scan. Furthermore, of the 800 patients without appendicitis, 160 patients will have a positive scan (.2 x 800). So, eventually there is a 160 / (200+160) = 44,4% chance on a false positive result (and most likely negative laparoscopy).

The second part: In 1000 patients, 50 will have appendicitis. Given the sensitivity is 100% these 50 patients will have a positive scan. Furthermore, of the 950 patients without appendicitis, 190 patients will have a positive scan (.2 x 950). So, eventually there is a 190/ (50+190) = 79,1% chance on a false positive result (and most likely negative laparoscopy).

Why pretest probability is absolutely essential

This quiz was written by Eefje Verschuuren, Nathalie Dollee Kirsten van der Zwet and Hüsna Sahin

Reviewed and edited by Rick Thissen

October 11, 2019November 20, 2020

Quiz 46, October 11th, 2019

Question 1

Which of the following statements is true about Wernicke’s Encephalopathy?

A: Administration of 100 mg IV thiamine prophylactically protects against deficiency for approximately one week

B: The 3 classic clinical features of Wernicke’s Encephalopathy are: ophthalmoplegia, paresis, and altered mental status/confusion

C: Only alcoholics get Wernicke’s Encephalopathy

Reveal answer

The correct answer is A

Wernicke’s Encephalopathy was discussed on the ever great Tox and Hound blog this week.

Administration of 100 mg IV thiamine prophylactically protects against deficiency for approximately one week.

The 3 classic clinical features include: ophthalmoplegia, ataxia, and altered mental status/confusion. And well, everybody can get Wernicke’s Encephalopathy, as long as you are thiamine deficient.

Tox and Hound – Don’t Wernicke’s, B(1) Happy

Question 2

According to this 2019 paper, can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome (ACS)?

A: Clinician gestalt is not safe to ‘’rule out’’ ACS

B: Clinician gestalt is sufficiently accurate to ‘’rule in’’ ACS

C: The ECG does not improve the Positive Predictive Value (PPV) when added to clinical gestalt to ‘’rule in’’ ACS

Reveal answer

The correct answer is A

REBELem covered this really interesting paper.

Clinician gestalt was not safe to ‘’rule out’’ ACS (NPV 95.0%) and not sufficiently accurate to ‘’rule in’’ ACS (PPV: 71.2%). The ECG did improve the Positive Predictive Value (PPV) when added to clinical gestalt to ‘’rule in’’ ACS (PPV 95%).

Can Emergency Physicians Use Clinical Gestalt to Predict Acute Coronary Syndrome?

Question 3

A 28-year-old male presents to the ED with hyperthermia, tachycardia and a yellow discoloration of the skin, eyes and body fluids. He states he just started a new weight loss supplement and his symptoms started about 5 hours after ingestion.

Which bodybuilding supplement is associated with these symptoms?

A: Creatine

B: Arginine

C: DNP (2,4-dinitrophenol)

D: Ginseng

Reveal answer

The correct answer is C

ALiem covered DNP intoxication last week.

DNP is a yellow organic compound which causes mitochondrial uncoupling, loss of ATP production and unregulated hyperthermia. It can affect all organ systems and can cause yellow discoloration of the skin. Symptoms will present within 4-8 hours. DNP is currently on the market as a weight loss agent.

The treatment exists of supportive care and management of hyperthermia.

ACMT Toxicology Visual Pearls: Getting Caught Yellow-handed

Question 4

A 37-year-old patient is brought to your Emergency Department after being shocked with a conductive energy device (CEW) (for example a TASER) for about 5 seconds. He is awake, alert and does not have any physical complaints.

Which of the following has to be part of your initial work-up?

A: Electrocardiogram

B: Serum CK

C: Electrolytes

D: None of the above

Reveal answer

The correct answer is D

This recently published paper was discussed on JournalFeed.

CEW’s give a jolt of 50.000 volts, which seems like a lot. If the duration of the shock was below 15 seconds (which should normally be enough for a defense mechanism) and your patient is awake and alert, there is no indication for ECG, prolonged cardiac monitoring or measurement of troponin. Also, no studies found electrolyte abnormalities. Marginal elevations of lactate and CK are occasionally encountered. A careful physical examination should be enough to rule out injury from the device.

Question 5

Source image: https://first10em.com/heparin/

Which of the following statements about Heparin in management of Acute Coronary Syndrome is true?

A: The practice of giving STEMI patients anticoagulation is based on strong evidence

B: There are no trials of Heparin in STEMI patients undergoing percutaneous coronary intervention (PCI)

C: Heparin is absolutely necessary for PCI

Reveal answer

The correct answer is B

Justin Morgenstern covered Heparin in STEMI and PCI on his latest post on First10EM.

‘’ The practice of giving STEMI patients anticoagulation has never been based on strong evidence. There are no trials of heparin in STEMI patients undergoing PCI, and the trials of heparin in thrombolysed patients are mixed and have significant flaws.’’

Heparin does not seem to be absolutely necessary for elective PCI neither, for the only strong evidence available (the CIAO trial) demonstrated harm from heparin in the setting of PCI for stable coronary artery disease.

Heparin in STEMI and PCI – does it help?

This quiz was written by Eefje Verschuuren, Nathalie Dollee Kirsten van der Zwet and Hüsna Sahin

Reviewed and edited by Rick Thissen

September 27, 2019November 20, 2020

Quiz 45, September 27th, 2019

Question 1

Which of the following statements is true about Point Of Care UltraSound (POCUS) assessment of free intraperitoneal air?

A: POCUS has a higher specificity for intraperitoneal air compared to an upright plain X-ray

B: Movement of reverberation artifacts with peristalsis indicates free intraperitoneal air

C: POCUS has a similar sensitivity for intraperitoneal air compared to CT abdomen

D: An enhanced peritoneal stripe sign (EPSS) is caused by a highlighted interface between gas and soft tissue

Reveal answer

The correct answer is D

EMdocs covered POCUS for diagnosis of free intraperitoneal air recently.

The sensitivity and specificity for pneumoperitoneum by POCUS are 92% and 53% respectively. The sensitivity is more or less equal to plain radiography. Movement of reverberation artifacts with peristalsis indicates intraluminal air. An enhanced peritoneal stripe sign (EPSS) is caused by a highlighted interface between gas and soft tissue. Normally (with fluid underneath) the peritoneum will only appear as a thin line.

Question 2

Which of the following statements is true about achilles tendon ruptures?

A: Ultrasound is useful to diagnose an achilles tendon rupture

B: The Thompson Test has a sensitivity of only 75%

C: Ultrasound can help differentiate between complete and partial ruptures

D: Operative management leads to better outcomes compared to conservative management

Reveal answer

The correct answer is C

BrownEM covered achilles tendon ruptures last week.

Imaging is not necessary for diagnosis of achilles tendon ruptures. The Thompson Test has a sensitivity of 96%. Nonoperative vs. operative management management remains controversial. And indeed, ultrasound can help differentiate between complete and partial ruptures.

Question 3

Your patient presents with an episode of AV Nodal Reentry Tachycardia (AVNRT) and you want to start with vagal manoeuvers. You wonder weather lifting her legs in the air after blowing the syringe is helpful at all. Is lifting the legs after blowing the syringe (Modified Valsalva) beneficial compared to just blowing a syringe (standard Valsalva) or does it just look silly according to recent evidence?

A: No, modified Valsalva is less effective compared to standard Valsalva

B: Modified Valsalva is equally effective compared to standard Valsalva

C: Modified Valsalva is more effective compared to standard Valsalva

Reveal answer

The correct answer is C

REBELem covered this paper last week.

Yes lifting the legs after Valsalva is definitely beneficial. Conversion to sinus rhythm within 60 seconds after manoeuvre was found to be 16% in the standard Valsalva group versus 46% in the modified Valsalva group.

Standard Valsalva vs Modified Valsalva for Cardioversion of SVT?

Question 4

Your pregnant patient is in her 3th trimester (29 weeks) and she presents to your department feeling generally unwell. Her blood pressure is measured twice at 160/100, 4 hours apart and her urine protein to creatinine ratio is 0.45. Does your patient have preeclampsia?

A: Yes, the diagnostic criteria have been met

B: No she does not have preeclampsia

C: Maybe, but it depends on thrombocyte count and transaminase levels

Reveal answer

The correct answer is A

NUEM published a great infographic about preeclampsia.

Diagnostic criteria are:
Blood pressure of ≥ 150 / 90 measured twice at least 4 hours apart or a blood pressure or ≥ 160/110 measured twice at least 15 minutes apart AND and-organ dysfunction. Just have a look at the infographic.

Question 5

The Mallampati score has become a routine part of airway screening in patients undergoing procedural sedation in the Emergency Department.

What is true about the accuracy and reliability of the Mallampati score?

A: The Mallampati score has a high sensitivity to predict a difficult bag-valve-mask ventilation, but lacks an adequate sensitivity to predict difficult intubation

B: The Mallampati score has a low sensitivity for predicting both a difficult bag-valve-mask ventilation and a difficult intubation. Furthermore, it has a poor inter-rater reliability

C: The Mallampati score has a high accuracy and reliability, but only in trained clinicians

Reveal answer

The correct answer is B.

This 2019 paper was covered on journal feed last week.

A recent literature review of the Mallampati score in ED airway management and procedural sedation showed a poor sensitivity in predicting difficult laryngoscopy (53%), difficult intubation (51%), and difficult bag-valve-mask ventilation (17%). The inter-rater reliability is also poor. Furthermore, the Mallampati score is designed to evaluate the patient in sitting position, with a wide opened mouth, a protruding tongue and remaining quiet. This can be challenging in critically ill patients (and children).

This quiz was written by Eefje Verschuuren, Nathalie Dollee Kirsten van der Zwet and Hüsna Sahin

Reviewed and edited by Rick Thissen

September 12, 2019November 20, 2020

Quiz 44, September 12th 2019

Question 1

Your 7 year old patient has been in a motor vehicle accident. On physical examination he has normal vital signs, but you notice an area of bruising on the lower abdomen.

Which of the following statements is true about seat belt injury in children?

A: The risk on intra abdominal injury is higher than the risk of spinal injury

B: The most common site of intestinal injury is the duodenum

C: Seat belt sign without abdominal tenderness is not associated with an increased need for surgical intervention

D: Small mesenteric tears and perforation are the most common hollow viscus injury

Reveal answer

The correct answer is D

Last weeks post on DFTB is about seat belt injuries.

The seat belt sign is associated with an increased risk of intra abdominal and even higher risk of spinal injury. The most common intestinal injury are small mesenteric tears or perforation of the jejunum, followed by injury to the duodenum. A seat belt sign is associated with a higher requirement for surgical intervention, even in the absence of abdominal tenderness.

Seat Belt Injuries

Question 2

You see a 16 year old patient who has been complaining about abdominal pain, nausea and vomiting for the past 24 hours. He has been smoking marihuana regularly for the past year, and you think his symptoms might be caused by cannabinoid hyperemesis syndrome.

Which of the following is not effective in this condition?

A: Ondansetron

B: Capsaicin topical cream

C: Hot shower

Reveal answer

The correct answer is A

Last week’s post on Pediatric EM Morsels covers Cannabinoid Hyperemesis Syndrome.

Cannabis consumption is very common. Cannabinoid Hyperemesis Syndrome causes cyclic nausea and vomiting. Symptom relief can be achieved by hot showers, topical capsaicin cream, and there have been some positive results with the use of haloperidol. Sadly, most anti-emetics (like ondansetron) are not effective.

Cannabinoid Hyperemesis Syndrome

Question 3

An 8-year-old female presents with pain on the lateral ankle. She is a dancer and she had no trauma in the past. The pain exists for 4 months and is worse while exercising. On X-ray you see a vertically oriented bone fragment of the base of MT 5. Your supervisor says it’s a MT5 apophysis. What is your diagnosis?

A: Osgood- Schlatter disease

B: Iselin disease

C: Kohler disease

Reveal answer

The correct answer is B

Iselin disease is also called traction apophysitis at the base of the 5th metatarsal. The pain typically begins after activity. It is a stress reaction at the insertion apophysis from overpull of the peroneus tendon. Do not confuse this on imaging with a base of the 5th MT fracture, these are typically horizontally oriented.

Osgood-Schlatter disease is a common cause of knee pain caused by overuse in growing adults.

Kohler disease is childhood osteonecrosis of the navicular bone.

SplintER Series: Ankle and Foot Pain in a Child

Question 4

Which of the following is NOT part of the HINTS exam in order to differentiate between peripheral and central vertigo?

A: Test of Skew

B: Nystagmus observation

C: Dix-Hallpike Manoevre

D: Head Impulse Test

Reveal answer

The correct answer is C

Taming the SRU covered the HINTS exam last week.

In the original study, a HINTS exam indicating peripheral etiology had a 100% sensitivity for ischemic stroke. However, a negative HINTS exam on its own should never prevent you from further examination. Furthermore, the HINTS exam hasn’t been validated for use by emergency physicians. Always keep pre-test probability in mind and be sure there is no additional focal neurological sign.

The HINTS test consists of: Head Impuls test, Nystagus and Test of Skew. Although Dix-Hallpike is not officially not part of this exam, it can be used to provoke nystagmus.

http://www.tamingthesru.com/blog/diagnostics/hints-exam

Question 5

In chemical sedation of the agitated patient, which of the following drugs has the fastest time of onset when given intramuscular?

A: Midazolam

B: Ketamine

C: Haloperidol

D: Droperidol

Reveal answer

The correct answer is B

NUEM covered chemical sedation of the agitated patient this week.

This post contains an excellent infographic about the various drugs used to sedate agitated patients in the ED. It seems ketamine (5 mg/kg im) has the fastest time of onset.

https://www.nuemblog.com/blog/chemical-sedation

This quiz was written by Eefje Verschuuren, Nathalie Dollee, Kirsten van der Zwet and Hüsna Sahin.

Reviewed and edited by Rick Thissen

August 28, 2019November 20, 2020

Quiz 43, August 28th, 2019

Question 1

Which of the following statements is true about the use of epinephrine in anaphylaxis?

A: Intramuscular (IM) epinephrine takes 30 seconds to reach peak blood levels

B: A bolus of 50 micrograms epinephrine intravenous (IV) should be given to patients with mild anaphylaxis

C: For severe hypotension, start epinephrine (IV) infusion at 20 micrograms per minute until the mean arterial pressure increases over 65 mm

D: Maintenance epinephrine infusion (IV) rate should be titrated within a range of 20-50 micrograms per minute

Reveal answer

The correct answer is C

Josh Farkas covered the benefits of IV epinephrine in the management of anaphylaxis this week.

His post is about patients who have pre-existing IV access and are being managed by a resuscitationist who is comfortable with the use of IV epinephrine. IV epinephrine has several potential advantages over IM epinephrine, including faster onset and greater titratability. An infusion of IV epinephrine provides greater control.

Patients in peri-arrest should get a bolus of 20-50 micrograms IV epinephrine. Patients with mild to moderate anaphylaxis should start on a loading epinephrine infusion at a rate of 20 micrograms per minute for 2 minutes. In case of severe hypotension, continue epinephrine at 20 micrograms per minute until the mean arterial pressure increases over 65 mm. Then the infusion rate should be dropped to 10 micrograms per minute and titrated to effect with a range of roughly 5-15 micrograms per minute. Begin weaning off epinephrine after 20-30 minutes of clinical improvement.

PulmCrit- How to use IV epinephrine for anaphylaxis

Question 2

Which of the following statements is true about SCUBA diving injuries?

A: The first symptoms of nitrogen narcosis can occur once descending past 10 meters (33ft)

B: Oxygen toxicity can occur without the use of enriched gas mixtures (O2 > 21%) or closed circuit rebreathers

C: A Non Rebreathing Mask is just as effective as hyperbaric therapy in treatment of barotrauma

D: Tooth fractures do occur due to barotrauma

Reveal answer

The correct answer is D

Diving injuries were covered on NUEM this week.

The first symptoms of nitrogen narcosis occur once descending past 30 meters (99ft).

Oxygen toxicity occurs due to the use of enriched gas mixtures (O2 > 21%) or closed circuit rebreathers.

All cases of barotrauma should be treated with hyperbaric therapy (hyperbaric chamber) if available. If not, use 100% oxygen and place the patient in horizontal position.

An yes, tooth fractures do occur due to barotrauma.

Question 3

Which of the following is NOT a side-effect of intravascular contrast used in CT-scanning?

A: Vasodilatation

B: Functional hypocalcemia

C: Osmotic diuresis

D: Change of urine color

Reveal answer

The correct answer is D

Justin Morgenstern discusses why patients are more likely to die during a CT-scan (if so) and why iv contrast might cause this.

It turns out contrast has a lot more side effects than anaphylactoid reactions and the feeling of peeing in the pants (vasodilation). The contrast binds calcium, resulting in functional hypocalcemia and it causes osmotic diuresis (which might harm the sick patient later on).

Click on logo for link to post

Question 4

Diagnosing Necrotising Fasciitis (NF) can be quite challenging. Fortunately The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was developed to make our lives a bit easier. Which statement is correct about this risk score?

A: This score has excellent diagnostic utility

B: Use it, but with caution. Sensitivity is likely around 80 percent

C: It is absolutely rubbish. Please do not use this score

Reveal answer

The correct answer is C

CountyEM covered necrotising fasciitis this week.

The original derivation study was retrospective observational. Validation studies showed poor sensitivity (around 50%) and specificity for the LRINEC score. It is not uncommon for fatal NF cases to have scores ≤ 2 (low risk).

Everything you ever wanted to know about Necrotizing Fasciitis

Question 5

Which of the following statements is true about colchicine poisoning?

A: Activated charcoal will not be effective in colchicine overdose

B: Most life threatening effects will occur within the first 12 hours after ingestion

C: There is no specific antidote

Reveal answer

The correct answer is C

Life in the Fast Lane covered colchicine poisoning this week.

Clinical symptoms of colchicine poisoning include: Gastrointestinal symptoms, cardiovascular collapse, coagulopathy and acute renal failure. The most dangerous phase is 2 to 7 days after ingestion. Administer activated charcoal as soon as possible as any reduction in absorption may be lifesaving and no, there is no specific antidote.

Colchicine toxicity

This quiz was written by Eefje Verschuuren, Nathalie Dollee, Kirsten van der Zwet and Hüsna Sahin.

Reviewed and edited by Rick Thissen

August 16, 2019November 20, 2020

Quiz 42, 16th of August, 2019

Question 1

This trial published earlier this year compared oral Ibuprofen at three single-dose regimens for treating acute pain in the emergency department. Which dose of ibuprofen was found to be most effective?

A: Doses of 400 mg, 600 mg and 800 mg were found to be equally effective

B: Doses 600 mg and 800 mg were found to be more effective than 400 mg

C: A dose of 800 mg was found to be more effective than 400 mg and 600 mg

Reveal answer

The correct answer is A

The authors conclude: Ibuprofen has similar analgesic efficacy profiles at single oral dosing regimens of 400 mg, 600 mg and 800 mg for short-term treatment of moderate to severe acute pain in the ED.

REBEL EM covered this paper last week. Keep in mind the follow-up time was only 60 minutes and patients who already received opioids were excluded.

A Randomized Control Trial Comparing Oral Ibuprofen at Three Single-Dose Regimens for Treating Acute Pain in the ED

Question 2

Which of the following signs is NOT commonly seen on ultrasound in the case of an occult supracondylar humerus fracture in children?

A: Bulging or the posterior fat pad

B: Lipohemarthrosis

C: Cortical disruption

Reveal answer

The correct answer is C

AliEM covered the diagnostic value of ultrasound in radiographically occult supracondylar humerus fractures in children.

Signs of potential occult fracture include a bulging posterior fat pad and lipohemarthrosis. It seems elbow ultrasound can assist in ruling out a supracondylar fracture because of it’s excellent sensitivity.

PEM Pearls: Ultrasound for Diagnosing Occult Supracondylar Fractures

Question 3

Source image: http://blog.clinicalmonster.com/2019/08/09/high-pressure-injection-injury/

Which of the following statements is true about the management of high pressure injection injuries in the Emergency Department?

A: Patients are often discharged home due to the benign initial appearance of the injury

B: Digital nerve blocks can be given safely

C: The most important prognostic factor is the result of microbiological culture

Reveal answer

The correct answer is A

County EM covered this topic last week.

Diagnosis is often delayed and patients are often discharged home due to the benign initial appearance of the injury which later results in amputation of the affected digit or hand. Do NOT perform digital nerve blocks given the risk of increased compartment pressure at the fingers. The most important prognostic factor is aggressive debridement by a hand surgeon within the first six hours following injury.

ED Management of High-Pressure Injection Injury

Question 4

A 42 year old patient with a history of alcohol abuse presents to your emergency department after he ingested half a bottle of antifreeze. What is correct about this intoxication?

A: Antifreeze contains propylene glycol

B: Acetonemia is typically seen in this intoxication

C: Hypocalcemia is typically seen in this intoxication

D: Optic Nerve Toxicity is typically seen in this intoxication

Reveal answer

The correct answer is C

This weeks blog on Taming the SRU is about toxic alcohols and covers the clinical presentation, diagnosis and management of this intoxication.

Antifreeze contains ethylene glycol and forms calcium oxalate crystals that can be seen with microscopic urine analysis. It can cause hypocalcemia, a wide QRS and prolonged QT.
Ingestion of methanol can cause blurred vision caused by optic nerve toxicity. Methanol is found in wiper fluid and paint. Isopropanolol is found in hand sanitizer and rubbing alcohol, and is broken down to acetone. Propylene glycol is used as a diluent for parenteral medications and can cause lactic acidosis. All of these toxic alcohols can cause CNS depression, GI symptoms and an increased osmol gap. For more about this topic you can read the following post.

Question 5

Source image: https://www.nuemblog.com/blog/pleural-effusions-101

What would probably be the best strategy to drain large pleural effusions keeping the risk of re-expansion pulmonary edema (REPE) in mind?

A: Limit initial fluid removal to 1,5 liters

B: Do not limit fluid removal, but stop the procedure when the patient is experiencing central chest discomfort

C: There are no limitations with regard to the drainage of large pleural effusions

Reveal answer

The correct answer is B

Josh Farkas wrote about large volume pleural drainage in his latest blog. Although there is no data to support it, traditional guidelines recommend a maximal volume of fluid removal of 1,5L during thoracentesis to prevent re-expansion pulmonary edema (REPE). Josh explains why this is arbitrary, and why the risk of REPE is probably due to the baseline size of the effusion rather than the volume of fluid removed.

In a large cohort study with 9320 inpatients who underwent thoracentesis, the rate of REPE after removal of >1,5L fluid was very low (0,75%). Josh concluded that large pleural effusions can generally be drained entirely, although the procedure should be stopped if the patient experience vague central chest discomfort.

Using multiple small-volume thoracenteses is a misguided strategy, since this causes an overall increase in procedural complications (bleeding, infection, lung laceration).

PulmCrit- Large volume thora: Can we drain ‘em dry?

This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Reviewed and edited by Rick Thissen